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Qt5gd2j43x.Pdf UC Irvine Clinical Practice and Cases in Emergency Medicine Title Uterine Body Stuffing Confirmed by Computed Tomography Permalink https://escholarship.org/uc/item/5gd2j43x Journal Clinical Practice and Cases in Emergency Medicine, 1(4) ISSN 2474-252X Authors Abesamis, Michael G. Taki, Najeeb Kaplan, Richard Publication Date 2017 DOI 10.5811/cpcem.2017.5.33495 License https://creativecommons.org/licenses/by/4.0/ 4.0 Peer reviewed eScholarship.org Powered by the California Digital Library University of California CASE REPORT Uterine Body Stuffing Confirmed by Computed Tomography Michael G. Abesamis, MD* *University of Pittsburgh Medical Center, Department of Emergency Medicine, Division Najeeb Taki, MD† of Medical Toxicology, Pittsburgh, Pennsylvania Richard Kaplan, MD† †Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania Section Editor: Rick A. McPheeters, DO Submission history: Submitted January 5, 2017; Revision received May 27, 2017; Accepted May 24, 2017 Electronically published October 18, 2017 Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.2017.5.33495 A 31-year-old woman presented to an emergency department for suspected vaginal “stuffing” of cocaine. Her physical and pelvic exams were unremarkable despite agitation, tachycardia and hypertension. Abdominal radiograph was concerning for foreign body; transabdominal ultrasound was non-diagnostic. A noncontrast abdominal/pelvic computed tomography (CT) revealed a radiopaque mass within the cervix extending into the uterus. Gynecology was consulted, but the patient refused removal and left against medical advice. Radiographs have varied sensitivity for detecting stuffed foreign bodies; CT is more sensitive and specific. This case suggests that CT is suitable to evaluate for this rare event. [Clin Pract Cases Emerg Med.2017;1(4):365–369.] INTRODUCTION department (ED) by police with suspected stuffing where the Body packing allows people to conceal and transport packet was eventually located in the uterus. illicit drugs across borders without detection. With increased scrutiny at borders throughout the United States, CASE REPORT law enforcement officials have noted that the rates of body A 31-year-old female was brought into the ED by local packing and stuffing have increased.1 More often, body police. A warrant for a cavity search accompanied the packers will ingest large amounts of drugs through the officers, as the patient had been suspected of stuffing gastrointestinal tract for later extraction and sale. These cocaine into her vagina when they apprehended her. The include sites such as the mouth, intestine and rectum.2 patient refused to provide any further details except to deny Body stuffing is a unique form of body packing. placing any objects into her vagina or rectum. “Stuffers” hastily place drugs in the mouth, vagina or rectum Her past medical history was positive for hypertension to quickly conceal available substances from law and noncompliance with her medications. Past surgical enforcement. Because of this, the amount of drug in history and family medical history was noncontributory. The “stuffers” is considerably less than “packers.”3 Moreover, patient denied alcohol, smoking or drug use, and she had no compared to “packers,” “stuffers’” drugs are often placed in known drug allergies. On review of systems, the patient poorly wrapped packaging that may rupture. Rupture of drug denied abdominal pain, chest pain, shortness of breath, contents into the patient’s system can lead to systemic effects pelvic pain, vaginal bleeding or vaginal discharge. The rest and even death.3,4,5 Because of the packaging differences, if of the 10-point review of systems was otherwise negative. they become symptomatic, effects generally present earlier On physical exam, vital signs included a blood pressure in body stuffers than with body packers.6 Common drugs of 148/110 mmHg, pulse of 125 beats per minute, used for body stuffing include cocaine, heroin, cannabinoids, respiratory rate of 16 per minute, and pulse oximetry of and methamphetamines.1 We present a unique case of a 100% on room air. She appeared to be a well-developed, 31-year-old female who was brought to the emergency well-nourished female in no acute distress. Head was Volume I, NO. 4: November 2017 365 Clinical Practice and Cases in Emergency Medicine Uterine Body Stuffing Confirmed by Computed Tomography Abesamis et al. atraumatic, normocephalic, and pupils were equal, round and reactive to light and accommodation. Cardiopulmonary CPC-EM Capsule exam was only significant for tachycardia. Her abdominal exam was unremarkable with normal bowel sounds, and no What do we already know about this clinical organomegaly, rebound or guarding. Rectal exam revealed entity? no evidence of foreign body. Pelvic exam disclosed normal Drug “stuffers” often place poorly wrapped external genitalia, no vaginal discharge, no cervical motion substances in orifices to conceal from law tenderness and no foreign body seen on speculum exam. enforcement. Rupture of the packaging can The cervical os appeared closed and normal but was not lead to systemic toxicity and death. digitally explored. Neurological and psychiatric exam were within normal limits. What makes this presentation of disease Urine pregnancy was negative and a kidney, ureter, reportable? bladder (KUB) radiograph was initially negative, but We present the first confirmed case of uterine over-read by radiology as concerning for foreign body in stuffing via computerized tomography. the right hemipelvis (Image 1). A transabdominal ultrasound was obtained, but was negative. The patient What is the major learning point? refused a transvaginal ultrasound. After consultation with Uterine stuffing is a rare but possible event radiology, a non-contrast computed tomography (CT) of which can be missed on physical exam. her abdomen/pelvis was performed to further delineate the Given the vascularity of the uterus, systemic location of the foreign body, revealing a tablet-like, toxicity is theoretically possible. radiopaque mass within the cervix that extended into the uterus (Images 2 and 3). How might this improve emergency Gynecology was consulted for removal of the uterine medicine practice? foreign body. However, the patient refused any further When assessing for uterine stuffing a non- testing or procedures. The hospital attorney was consulted contrast computerized tomography scan and the emergency physician was informed that the patient of the abdomen and pelvis is adequate to could not have the foreign body removed against her evaluate for this rare event. volition. The patient signed out of the ED against medical advice. Since no physical evidence could be produced, the patient was released by the police. DISCUSSION This case demonstrates a unique event in relation to illicit substance stuffing. This patient had a suspected been studied in body stuffing, and utility would likely vary cocaine bag in her uterus that we believed she stuffed. To on the body cavity involved and the amount of drug placed. our knowledge, this is the first documented case in the In this case, ultrasound was not useful likely due to the literature. This “stuffing” was concerning as intravaginal uncooperative patient, inability to perform the study toxicity due to stuffing has been described in the past,4 and transvaginally, and operator-dependent differences. given the vascularity of the uterine bed, toxicity from drug Abdominopelvic CT is considered the most accurate method exposure from this site is a significant possibility. of diagnosis of body packing/stuffing with sensitivity Evaluating which method would be best to assess a between 77-100% and specificity of 94-100%.10,11 Evidence similar case was explored. In reviewing the past stuffing/ for the use of CT with or without oral contrast in evaluating packing literature, we found that radiographs have been cases of body packers and stuffers has been limited. reported to have a sensitivity that varies dramatically (47% However, recent studies suggest that CT without oral - 95%) in finding stuffed/packed foreign bodies.7 This was contrast is more sensitive and has an equal positive thought to be secondary to the different radio-opacities of predictive value compared to CT with oral contrast.12 the substances (cannabis is radiopaque, cocaine is isodense, “Stuffers” generally wrap drugs in materials such as and heroin in radiolucent) and the packaging materials cellophane, plastic bags, aluminum foil, glassine crack used. CT is considered to be more sensitive than vials, or wax paper,3 due to the rapid manner in which they radiographs in locating foreign bodies.8 One study suggests attempt to hide the substances. These are more likely to ultrasound as a possible screening tool with a positive rupture or leak; therefore, one must keep a high vigilance predictive value of 97% and an accuracy of 94% in especially in cases that have negative clinical findings. searching for intestinal foreign-body packing,9 but it has not Rupture of the contents can lead to disastrous Clinical Practice and Cases in Emergency Medicine 366 Volume I, NO. 4: November 2017 Abesamis et al. Uterine Body Stuffing Confirmed by Computed Tomography Image 1. Kidney, ureter, bladder radiograph with arrows showing an area concerning for a possible foreign body in the right hemipelvis Image 2. Coronal computed tomography of the abdomen/pelvis with arrows revealing a tablet-like, radiopaque mass within
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